- Breathlessness (See Also Chapter 10)
- Neuro-Ophthalmic Problems (See Also Chapter 14)
- Acute Diarrhoea (See Also Chapter 22)
Author(s): Mas Chaponda and Nick Beeching
Human immunodeficiency virus (HIV) positive patients get common diseases as well as those that reflect their immune deficiency. The spectrum of HIV infection is summarized in Box 34.1.
- Establish from the patient who knows about the HIV diagnosis among the patient's relatives and friends: be sensitive to their needs and respect the patient's right to confidentiality.
- Take appropriate safety precautions when handling any body fluid and label specimens according to local policies.
- The management of acute medical problems in the patient with HIV/AIDS is often complex, and you should seek advice from an infectious disease (ID) physician early on.
Breathlessness (See Also Chapter 10)
Pulmonary infection (especially with Pneumocystis jirovecii pneumonia) remains the most common acute presentation of HIV-positive patients. Causes to consider are given in Table 34.1. Management is summarized in Figure 34.1.
- Attach a pulse oximeter and check arterial blood gases: the patient may be severely hypoxaemic with minimal lung signs. Give oxygen to maintain arterial oxygen saturation >90%. Investigations needed urgently are given in Table 34.2.
- Your clinical assessment and the chest X-ray appearance may provide clues to the likely diagnosis (Table 34.3).
- Dual pathology is relatively frequent, and definitive diagnosis depends on microbiological findings.
- Initial treatment for suspected Pneumocystis jirovecii pneumonia (PCP) is given in Table 34.4.
- Seek advice from a chest physician and ID physician on further management. Examination of induced sputum and/or bronchoscopic alveolar lavage fluid are often helpful in making a diagnosis.
Neuro-Ophthalmic Problems (See Also Chapter 14)
With improved PCP prophylaxis, HIV-positive patients are presenting more frequently with neuro-ophthalmic problems (Table 34.5).
Delirium with or without headache (see also Chapters 4 and 15)
Consider toxoplasmosis, cryptococcal meningitis (Appendix ), cerebral lymphoma and progressive multifocal leucoencephalopathy. HIV encephalopathy is diagnosed by exclusion of other causes.
- Arrange urgent cranial CT or MR scan.
- Perform a lumbar puncture (LP) if the scan is normal. Send CSF for cell count; protein concentration; glucose (fluoride tube, together with blood glucose at same time); Gram, Ziehl–Neelsen and India ink stains; and culture and specific tests for Cryptococcus spp., Toxoplasma gondii and mycobacteria.
- If no specific diagnosis can be made, consider giving empirical treatment for toxoplasmosis with pyrimethamine and sulphadiazine, and repeat the scan after 2–3 weeks.
- Seek advice from an ID physician and neurologist.
Focal upper motor neuron signs
- Consider toxoplasmosis or lymphoma.
- Arrange urgent cranial CT or MRI.
- Perform a LP if the scan is normal, and send CSF for investigation as above.
- If focal lesions (ring-enhancing, with surrounding oedema on CT), treat as toxoplasmosis.
- Seek advice from an ID physician and neurologist.
- Consider sterotactic biopsy.
Impaired vision (see also Chapter 19)
Ophthalmic complications are more likely in advanced HIV and CD4 T cell count <50, particularly cytomegalovirus (CMV) retinitis and toxoplasmosis. Syphilis and tuberculosis may also affect the eye and may occur at any CD4 count.
- Suspect CMV retinitis: fundoscopy shows characteristic infiltrates, similar in appearance to soft exudates.
- Seek advice from an opthalmologist.
- Treatment is with ganciclovir (or cidofovir or foscarnet if ganciclovir is contraindicated; both are nephrotoxic). Gancicovir and its oral form valganciclovir can cause severe marrow depression which must be monitored.
Acute Diarrhoea (See Also Chapter 22)
See Chapter 22 for the assessment and management of the patient with acute diarrhoea.
Establish the differential diagnosis from the history and examination (Table 22.1). Strict infection control protocols must be followed (including barrier nursing and hand-washing). Investigations needed urgently are given in Table 22.2.